Cancer Studies Contact Form

Has the patient received care at Mayo Clinic before?

Yes

No

Don't Know

Requester (non-patient) Information

If you aren't the patient, please answer the questions below and then complete the patient information for the patient. If you are the patient, please skip this section and complete only the patient information section.

Mayo Clinic Number

Your Mayo Clinic number is a 7, 8 or 9-digit number we assign to you as a new patient prior to your first visit. You can find it near the top of a range of documents, including pre-visit questionnaires, clinical notes, care summaries, and correspondence.

If you do have Mayo paperwork handy, it's often quickest simply to look for it there. Scroll down to see some examples of how the number shows up:

In correspondence:

In pre-appointment questionnaires

In medical documents:

In dismissal summaries:

In several other kinds of documents:

Additional Information

What motivated you to contact the Mayo Clinic? Select all that apply.

Internet / media / print

Former Mayo Clinic experience

Exhausted local options

Mayo Clinic reputation

Other

Are you taking anti-convulsants or anti-seizure medications?

Yes

No

Don't know

Do you have a history of heart problems?

Yes

No

Don't know

Do you have cancer?

Yes

No

Cancer type:

Is this a new diagnosis?

Yes

No

Don't know

Has the cancer spread to the brain?

Yes

No

Don't know

Have you had chemotherapy?

Yes

No

Don't know

If yes, please enter the names of the chemotherapy drugs.

Have you had hormonal therapy for cancer treatment?

Yes

No

Don't know

Have you had radiation

Yes

No

Don't know

If no, is there a particular study about which you'd like more information?

Does Mayo Clinic have your permission to communicate with you via email?